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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard <br /> Date run: 4/18/2017 <br /> Submitted on: 4/14/2017 7:03:50AM CERS ID: 10184507 <br /> Submitted by: Cynthia Hutchison Email: cynthia.hutchison@davita.com Facility ID in CERS: FA0013665 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Number of Facilities for this Owner: 1 <br /> Owner ID OW0010774 <br /> Owner name DVA Healthcare Renal Care, Inc. DVA Healthcare Renal Care, Inc. 111 <br /> Mailing address 2000 16th Street 2000 16th Street 113 <br /> Denver, CO 80202 Denver, CO 80202 114, 115, 116 <br /> Work phone 303-405-2100 303-405-2100 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013665 <br /> Facility name DAVITA MANTECA DIALYSIS CENTER DAVITA MANTECA DIALYSIS CENTER 3 <br /> Site address 1156 S MAIN ST 1156 S MAIN ST 103 <br /> City MANTECA MANTECA 104 <br /> ZIP code 95336 95336 105 <br /> Facility phone 209-823-3078 2098233078 102 <br /> Facility mailing address 1156 S MAIN ST 1156 S MAIN ST 108a <br /> MANTECA, CA 95337 MANTECA, CA 95337 108b, 108c,108d <br /> BILLING INFORMATION <br /> Contact name Sharon Edmondson Cindy Hutchison 140 <br /> Address 5200 Virginia Way 5200 Virginia Way L&C Dept 143 <br /> Brentwood, TN 37027 Brentwood, TN 37027 144, 145, 146 <br /> Contact phone 615-324-1678 615-341-5895 141 <br /> Contact email Sharon.edmondson@davita.com Cynthia.Hutchison@davita.com 142 <br /> Mail invoices to Account <br /> Program record [ ] HMBP [ ] SQG HW [ ] LQG HW [ ] RCRA HW New PR#: <br /> created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST New PE: <br /> Assigned to: <br /> Please bill: [ ] full calendar year [ ] prorate this calendar year ([ ]] nexxt calendar year [ ] exempt from billing <br /> Processed through CERS Integration Wizard by: 09^-% I� i Date: t M—kk 7 <br /> -- -- ----- ------- -------------- ------- ------ -- --- - -- <br /> Accounting: Reviewed by: Ub Date: 41(c1l 1 ? Clerical: [ ] File [ ] Relabel file [ ] Create new file <br /> [ 1--,Acct biller+ ��r�h�verified By: Date: <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Record ID Employee name Status Reactivated Inactivated <br /> 1921 -HMBP-Regular-Primary Location 4 chem units PR0521008 NICHOLAS LOEHRER Active [ ] [ ] <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0518047 HAZ MAT SJC OES Inactive [ ] [ ] <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FEE PR0518046 HAZ MAT SJC OES Inactive [ ] [ ] <br /> 4530-LG QUANITY GENERATOR PR0522691 ROBERT MCCLELLON Inactive [ ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PR0534743 not assigned Inactive [ ] [ ] <br />